Provider Demographics
NPI:1497803860
Name:PRUITT, JEFFERY RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:RANDALL
Last Name:PRUITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6309
Mailing Address - Country:US
Mailing Address - Phone:405-359-5370
Mailing Address - Fax:405-359-5357
Practice Address - Street 1:ONE S BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6309
Practice Address - Country:US
Practice Address - Phone:405-359-5370
Practice Address - Fax:405-359-5357
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23454207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200108630AMedicaid
OKOKB5121Medicare PIN
OKOK700186Medicare PIN
OK200108630AMedicaid
OKP00658672Medicare PIN